CNA student registration – Students System

– Step 1 of 8

Trainee Application

Full Name: *

First

Middle

Last

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GENDER: *

MALE
FEMALE
OTHER

STATE OR SELF: *

STATE
SELF
OTHERS

OTHERS:

STATE: *

CCAP
EQUUS
DLT
ORS
WFS
RIIC
OTHERS

RACE: *

AMERICAN INDIAN OR ALASKA NATIVE
ASIAN
BLACK OR AFRICAN AMERICAN
HISPANIC
MIDDLE EAST OR NORTH AFRICAN
NATIVE HAWAIIAN OR PACIFIC ISLANDER
WHITE

CASE WORKER NAME

CASE WORKER PHONE

CASE WORKER EMAIL

Class *

Date: *

Address: *

Address Line 1

Address Line 2

City

State

Zip Code

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Phone: *

Email *

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Date of Birth: *

Social Security# *

Desired Start Date: *

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Are you a RI Resident? *

If no, are you authorized to study in the U.S.? *

Have you previously held a CNA license? *

If yes, when?

Have you ever been convicted of a felony? *

If yes, explain?

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge.

If this application leads to enrollment, I understand that false or misleading information in my application may result in dismissal.

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Signature: *

Date: *

Uniform Size

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Scrub Top

Scrub Botton

Multiple Choice

Short
Standard
Tall

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AGREEMENT FOR NURSING ASSITANT TRAINING

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Name *

understand that the cost for the nursing assistant training program is as follows:

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Tution: $1200

Documentation Fee: $600

Books / Materials / Handouts: $200

Fee For Medical Supplies: $200

Uniforms / Badge: $100

TOTAL: $2,300

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If I decide to withdraw before the starting date of the course

Date

I understand this includes a $100 non-refundable registration fee. If I decide to withdraw after the starting date of the course. I understand that I am responsible for payment in full. No refund is available after the starting date of the course.

All my questions have been answered, and I understand my financial obligations to Hitep Inc.

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Trainee Print Name: *

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Trainee Signature: *

Date: *

HITEP Emergency Contact Form

Name: *

First

Middle

Last

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Phone Number: *

Address: *

Primary Emergency Contact Name: *

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Relationship: *

Cell Number: *

Second Emergency Contact Name:

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Relationship:

Cell Number:

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Any special medication taken (if any):

Allergies (if any):

This information is very important to us at HITEP, your safety is our priority.

Please ensure that all information provided is correct, once done, sign and date below.

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Student Signature: *

Date: *

RELEASE AND WAIVER OF LIABILITY

In consideration of my participation in the HITEP Nursing Assistant Training Program, I, the undersigned (or my parent or legal guardian if I am a minor), hereby waive, release, and forever discharge HITEP, its affiliates, directors, agents, employees, and representatives from all liability, including future damages, for injuries or damages of any kind resulting from my participation in the Nursing Assistant Training Program. I have voluntarily and knowingly agreed to participate in the certified nursing assistant training and assume full responsibility for my participation and activities in said training.

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Signature of Participant: *

Printed Name of Participant: *

Date *

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Signature Parent or Legal Guardian if Minor:

Print Parent or Legal Guardian if Minor:

Date

Photography authorization

I hereby give my consent for all photographs taken of me by HITEP staff to be used for illustrative, advertising, school website information/promotion or publication purposes.

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Trainee’s Signature : *

Notes:

Date: *

Family Educational Rights and Privacy Act (FERPA)

FERPA CONSENT TO RELEASE APPRENTICE INFORMATION

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TO: HITEP, Inc.

Please provide educational records information from

Name *

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[Name of student requesting release of educational records] to:

Name *

[Name(s) of the person(s) to whom the educational records will be released and, if applicable, their relationship to the student, such as “parents,” “prospective employer,” or “attorney”]

(Note: This consent does not cover medical records.)

The only type of information that is to be released under this consent is:

Grades, competencies
Disciplinary records
Recommendations for employment or admission to other schools
All records of education
Other (example): Absent explanations, notes, etc….

The information will be disclosed for the following purpose: At the student’s request.

I understand that the information may be disclosed in the form of copies of written records, as preferred by the requester. I have the right to inspect any written records disclosed under this Consent. I understand that I may revoke this Consent by providing written notice to HITEP. Furthermore, I understand that until such revocation occurs, this consent will remain in effect and my educational records will continue to be provided to the person named above, to whom they will be disclosed for the specific purpose described.

Name (print): *

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Signature *

Date: *

Checklist for students in the nursing assistant training program

Checkboxes

Fill out and complete registration application form
Submit Payment of course
Complete and sign agreement forms (if applicable)
Social Security
ID or driver´s license
Complete and sign FERPA form
Sign photo release (unsigned release will indicate release of photo is not permitted)
Determine uniform size and obtain photo for badge
Review trainee health requirements and precautions- Covid Card
Submit proof of physical exam and required immunizations
Submit Original BCI (State Background Check) with stamp and seal from the RI Attorney General’s Office only. BCI must be given by Orientation.

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Trainee Signature: *

Date: *

FOR OFFICE USE ONLY:

The checklist has been reviewed and the trainee understands the eligibility requirements.

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Staff Signature: *

Date: *

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Name *

Please understand that the nursing assistant training program is conducted in English, as required by the Rhode Island Department of Health. Students may use resources to facilitate translations into Spanish, such as:

Use your phone to translate
Written materials, exams, and study guides
The book is delivered in English

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Ellos,

Name *

I understand that the nursing assistant training program is conducted in English as required by the RI Department of Health. Students are permitted to use resources to assist with Spanish translation, such as:

Use your phone to translate
Written materials, exams, and study guides
The book is delivered in English

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Signature: *

Date: *